Certificate Requests

Please complete the form below. All fields with asterisks are required. Note that no changes will take effect until you receive a confirmation from us.
  I. Please identify yourself
Your name 
Insured 
Insured shown
on certificate 
Phone*  
Fax  
Email* 
 
  II. Additional interest / Certificate holder
Company Name* 
Address* 
City* 
State*  Zip Code -
Phone  
Fax  
Email 
 
  III. Additional interest nature
   (skip if certificate is for evidence of insurance only)
Additional
Interest Nature 
Addt'l Insured
 Addt'l Insured Lessor & Loss Payee(Leased Equipment)
Addt'l Insured & Loss Payee for Auto Policy
Addt'l Insured and Mortgagee
Addt'l Insured Manager/Lessor (CG 20 24) - Landlord
Owner, Lessee, Contractor (Form B, CG 20 10)
       Work Performed

Additional Insured Vendor
Loss Payee
 
  IV. Interest in relation to
Vehicle 
Equipment 
Location 
Job 
Other 
 
  V. Policies to be shown
Policies to be
shown 
General Liability  Automobile  Umbrella  
 Workers Compensation  Property
 
  VI. Description to read
 
  VII. Deliver certificate by
Mail 
Fax 
Email 
 
  VIII. Special Instructions
Please note that no changes will take effect until we review your request and you receive a confirmation from us. This will usually occur during normal business hours.

Plainview      New York City      Westhampton      Saratoga

Tel: (516) 938-9000 • Email: cbs@cbsinsurance.com

© 2005 CBS Coverage Group, Inc. All rights reserved.